PUEBLO, CO-PUEBLO CENTER

The Department of Health & Human Services conducted an inspection of the facility. The following highlighted decencies listed below were found in a public survey. 

Ensure services provided by the nursing facility meet professional standards of quality.

Based on observations, record review and staff interviews the facility failed to provide services for three (#4, #12 and #36) of four reviewed out of 39 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #4, Resident #12 and Resident #36’s vital signs were monitored prior to the administration of a blood pressure medication.

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Based on observations, record review and interviews the facility failed to ensure one (#14) of one residents reviewed for activities of daily living were provided with services or treatments to prevent the reduction in range of motion out of 39 sample residents.

Specifically, the facility failed to ensure Resident #14 was provided with preventative measures to help minimize the development of and the worsening of contractures. Resident #14 had a contracture to his left hand and no preventative measures were implemented.

When Resident #14 was assessed during the survey on 10/31/23, his left hand finger contractures worsened and he developed a contracture to his right hand.

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Based on record review and interviews the facility failed to coordinate assessments with the preadmission screening and resident review (PASRR) program for two (#16 and #32) of nine residents reviewed for PASRR out of 39 sample residents.
Specifically, the facility failed to:
-Ensure a PASRR level II evaluation was available in the medical record of Resident #16 with a known major mental illness; and,
-Ensure a PASRR level II evaluation was completed for Resident #32 after the resident was identified as having a known major mental illness

Ensure services provided by the nursing facility meet professional standards of quality.

Based on observations, record review and staff interviews the facility failed to provide services for three (#4, #12 and #36) of four reviewed out of 39 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #4, Resident #12 and Resident #36’s vital signs were monitored prior to the administration of a blood pressure medication.

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Based on record review and interviews, the facility failed to ensure a discharge summary was in place for one (#86) resident out of three sample residents reviewed for discharge out of 39 sample residents. Specifically, the facility failed to ensure discharge summaries included a recapitulation of the resident’s stay, a final summary of the resident’s status and recapitulation of the resident’s stay at the facility for Resident #86.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for two (#14 and #53) of three residents reviewed out of 39 sample residents. Specifically, the facility failed to ensure Residents #14 and #53 received assistance with showers as scheduled.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on observations, record review and interviews, the facility failed to ensure that the resident ‘ s environment was free from accident hazards for one (#4) of three resident reviewed for falls out of 39 sample residents.
Specifically, the facility failed to:
-Ensure that fall risk assessments were in place, before and after a fall, for Resident #4 with a history of falls;
-Document neurological assessments after Resident #4 fell ; and,
-Document an interdisciplinary team (IDT) review to establish causative factors of the fall and failed to implement and care plan new interventions.

Neurological assessments are indicated: upon physician order, following an unwitnessed fall, following a fall or other accident/injury involving head trauma, or when indicated by resident ‘ s condition.